Just-released Clerkship Study

What has appeared to be solid progress toward growing an adequate U.S. health care workforce could be derailed by an escalating shortage of clinical training sites to accommodate many of those learners.

FP Kendall Campbell, M.D., works with medical student Vishal Dahya to assess a patient at Neighborhood Health Services, an indigent care clinic located in Tallahassee, Fla.

That's the crux of the message delivered in a recently released report(www.aamc.org) titled Recruiting and Maintaining U.S. Clinical Training Sites: Joint Report of the 2013 Multi-Discipline Clerkship/Clinical Training Site Survey.

The report, which was jointly developed by the American Association of Colleges of Nursing, the American Association of Colleges of Osteopathic Medicine, the Association of American Medical Colleges and the Physician Assistant Education Association, chalks up the shortage, in part, to the opening of new allopathic and osteopathic medical schools, the expansion of existing schools, and larger class sizes. (Total U.S. medical school enrollment increased by 23 percent(journals.lww.com) between 2000 and 2010.)

Authors also pointed to an explosion in the number of training programs for nurse practitioners (NPs) and physician assistants (PAs), as well as a growing number of Caribbean-based medical schools seeking U.S. training experiences for their students.

Story Highlights

A recently released clerkship study breaks down survey results to determine how the shortage of U.S. clinical training sites is affecting medical schools.

The shortfall is driven, in part, by a surge in the number of medical students from both U.S. academic institutions and Caribbean-based medical schools and threatens to limit future growth of U.S. medical schools.

Medical schools across the country are working proactively to find creative ways to ensure their students continue to receive quality clinical training.

"It's a tsunami. And this crisis is really going to hit fever pitch in a few years," said Gary LeRoy, M.D., an associate professor of family medicine and associate dean for student affairs and admissions at Wright State University Boonshoft School of Medicine in Dayton, Ohio. LeRoy told AAFP News he had watched the trend develop -- and warned of its consequences -- for the past five years.

"And it's happening all across the nation," he said. "It's not just a Wright State problem by any stretch of the imagination."

The survey on which the report was based was designed to explore the concerns of medical schools and NP and PA programs, all of which have students competing for invaluable hands-on clinical training.

The resulting report found that

across all four disciplines, most respondents said finding clinical training sites for their students had become more difficult;

more than half of respondents felt pressured to pay for training sites; and

many respondents had implemented nonmonetary incentives and alternative solutions to address training site shortages.

Addressing the Problem in Ohio

According to LeRoy, Boonshoft Medical School could see its growth stilted in the future as the shortage of clinical training sites limits the school's enrollment capacity. And 57 percent of M.D. schools that responded to the survey face the same dilemma.

LeRoy said his medical school had methodically increased its class size every few years since 2000 to a record 110 students in 2014 in an attempt to prepare for the predicted U.S. physician shortage.

"We can physically accommodate about 120 students, but we have to critically look at all of our clinical sites within the community and ask if they can accommodate that number," said LeRoy.

Medical schools typically place their third-year students in clerkship rotations in the specialties of family medicine, internal medicine, pediatrics, OB/Gyn, general surgery and psychiatry.

Some adjustments are underway at Boonshoft to make the most of training opportunities. For example, for their pediatric rotation, students choose between the day and the night shifts to take full advantage of all 24 hours of the day.

Julie Fashner, M.D., a family physician, observes medical student Louis Gerena as he checks a toddler's ears at the Family Medicine Center at Lee Memorial Hospital in Fort Myers, Fla.

LeRoy lamented the dwindling number of private-practice physicians because that further erodes the pool of physicians he can count on to precept. "Employed doctors are being told 'Hey, you're a great teacher ... but we don't want to accept the potential financial consequences of having a medical student slow you down,'" he said.

Still, LeRoy said he draws the line at simulation-based training sessions reportedly used by some 58 percent of M.D. schools. He said the strategy "short-changes" students.

"Medicine is a people-driven profession; our patients are at the center of it all," said LeRoy. "Even though simulators (purportedly) can teach students how to deliver a baby, put in an IV line, or how to run a code, it's a whole different dynamic when you have a living, breathing person there in front of you.

"Students have to be put in those real-time, real-life environments," said LeRoy.

Easing the Bureaucracy in Nevada

Family physician Thomas Schwenk, M.D., dean of the University of Nevada School of Medicine in Reno and vice president of the University of Nevada, Reno, Division of Health Sciences, said the growth and expansion of medical schools is only part of the story.

"This goes beyond capacity issues. I actually think there's something else happening, and that is a greater appreciation for the value of community-based teaching and the engagement of community-based physicians -- as well as the need to diversify the experience of students," he said.

"Every school, in its own way, is trying to figure out how to tap into that physician resource," Schwenk noted. But at the same time, he added, the clinical training process has become more formal, bureaucratic and complicated because of the demands of the Liaison Committee on Medical Education and other accrediting bodies.

Schwenk said he has a deep-seated belief that community physicians are looking for more than traditional perks such as parking passes or football tickets or a minimal stipend that can never really make up for the lost productivity that occurs when a physician precepts a student in his or her office.

Medical student Christina Gutierrez learns how to examine a patient's feet under the tutelage of family physician Noel Roncal, M.D., at the Family Medicine Clinic at Healthcare Network of Southwest Florida.

"We have a tremendous outpouring of support from physicians in the Reno community, but every time they say they're interested in taking students, they also say, 'You've got to get this organized, you've got to do this differently than schools have done it in the past,'" said Schwenk.

His medical school is in the midst of creating what he called an "office of community physician faculty engagement" that will assist preceptors with all the messy issues that come with the job -- from scheduling training slots to completing evaluation forms to dealing with performance issues involving student-learners.

The idea, said Schwenk, is to engage physicians through logistics and infrastructure and support. "All the physicians will have to do is what they really want to do, and that is to teach," he noted.

Getting Back to Basics in Florida

Florida State University (FSU) College of Medicine in Tallahassee is one of the nearly 20 percent of medical schools cited in the report that indicated they had experienced no shortage of clinical training sites.

Dean John Fogarty, M.D., credited his school's unique model -- with its six regional campuses and more than 2,800 community-based physicians -- for ensuring that students have notable clinical experiences.

"Our students are in an office-based setting with a board-certified doc caring for 200 patients, and it's a one-on-one relationship for six or eight weeks," said Fogarty. "Compare that to the typical medical student training on a hospital ward with a team where the student is the low man on the totem pole, doing the scut work, taking care of one to three patients at any given time," he added.

FSU preceptors are paid a stipend of $500 a week for a six-week rotation, but Fogarty insisted there was more to physicians' interest in precepting than money. In fact, about 10 percent of preceptors return their checks to the school, he said.

"Our community physicians feel like they are critical to our educational program," said Fogarty, who makes a point of visiting each of those regional campuses on a regular basis to very publicly thank those community physicians in a sort of "state-of-the-school" address. He added the community apprenticeship model is thriving because it puts students where the majority of patients are these days -- in outpatient community clinics, not in hospital beds.

Connecting With Preceptors

AAFP News reached out to several family physicians who routinely take students into their practices and serve as that personal guide to the intricacies of the specialty.

Charles Rhodes, M.D., of Cabarrus Family Medicine in Mount Pleasant, N.C., admitted that teaching could slightly alter a physician's bottom line if his or her idea of compensation was based solely on practice income.

"But there are so many upside benefits to teaching," Rhodes said. "It keeps me fresh and current because medical students ask a lot of questions, and I find myself constantly looking up things to be sure I am giving them accurate information. Students also bring new ideas and concepts from the medical schools with them, so in teaching them, I also learn," he added.

Overall, said Rhodes, "Students inspire me and give me hope for the future. Practice without students would be less interesting and less enjoyable."

Jennifer Miley, M.D., is co-owner of a three-physician private practice in Pensacola, Fla. She said teaching helps foster a feeling that she is "paying forward" the great mentoring experiences she had as a student.

"The students really add some variety to my day, which is part of the reason I chose family medicine," said Miley.

John Bullock, M.D., of Hattiesburg, Miss., operates a clinic in Sumrall that is part of a larger, physician-owned multispecialty clinic. "I precept students mostly to help those young people who are interested in the field get a true view of the profession and to help them decide if this is the specialty for them before they make a full commitment," he said.

Although a student can cause a slow-down in a very busy clinic, "There is reward in their interest and in the fact that they help keep us sharp and up-to-date," said Bullock.

Aaron Garman, M.D., serves as the medical director of a federally qualified community health center in Beulah, N.D. "Helping teach medical students is one of the pleasures of practicing in general, and it gives me great pride to help educate students and get them excited about medicine," he said.

"Their enthusiasm is contagious and helps foster the love of my job. The only drawback is time itself -- not having enough time to spend with students and only getting to work with them for one month at a time."